FEDERAL EMERGENCY MANAGEMENT AGENCY
REQUEST FOR PUBLIC ASSISTANCE
O.M.B. No. 3067-0151 Expires April 30, 2001
PAPERWORK BURDEN DISCLOSURE NOTICE Public reporting burden for this form is estimated to average 10 minutes. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the needed data, and completing and submitting the forms. You are not required to respond to this collection of information unless a valid OMB control number is displayed in the upper right corner of the forms. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (3067-0151). NOTE: Do not send your completed form to this address.
APPLICANT (Political subdivision or eligible applicant.) DATE SUBMITTED
COUNTY (Location of Damages. If located in multiple counties, please indicate.)
APPLICANT PHYSICAL LOCATION
STREET ADDRESS
CITY
COUNTY
STATE
ZIP CODE
MAILING ADDRESS (If different from Physical Location)
STREET ADDRESS
POST OFFICE BOX
CITY
STATE
ZIP CODE
Primary Contact/Applicant’s Authorized Agent
NAME NAME
Alternate Contact
TITLE
TITLE
BUSINESS PHONE
BUSINESS PHONE
FAX NUMBER
FAX NUMBER
HOME PHONE (Optional)
HOME PHONE (Optional)
CELL PHONE
CELL PHONE
E-MAIL ADDRESS
E-MAIL ADDRESS
PAGER & PIN NUMBER
PAGER & PIN NUMBER
Did you participate in the Federal/State Preliminary Damage Assessment (PDA)? Private Non-Profit Organization? Yes No If yes, which of the facilities below best describe your organization?
Yes
No
Title 44 CFR, part 206.221(e) defines an eligible private non-profit facility as: “… any private non-profit educational, utility, emergency, medical or custodial care facility, including a facility for the aged or disabled, and other facility providing essential governmental type services to the general public, and such facilities on Indian reservations.” “Other essential governmental service facility” means museums, zoos, community centers, libraries, homeless shelters, senior citizen centers, rehabilitation facilities, shelter workshops and facilities which provide health and safety services of a governmental nature. All such facilities must be open to the general public.
Private Non-Profit Organizations must attach copies of their Tax Exemption Certificate and Organization Charter or By-Laws. If your organization is a school or educational facility, please attach information on accreditation or certification.
Official Use Only: FEMA-DRFIPS # Date Received:
FEMA Form 90-49, SEP 98
REPLACES ALL PREVIOUS EDITIONS.